Taking Folic Acid Before You Get Pregnant

Research shows that women who take vitamins that contain folic acid may lower the risk that their baby will be born with a birth defect called a neural tube defect. Between 2 and 4 babies of every 1000 babies born in Canada have neural tube defects.

What is a neural tube defect ?
A neural tube defect happens when something interferes with the way the baby grows before he or she is born. The two most common conditions in which neural tube defects occur are spina bifida and anencephaly. These conditions may be prevented if women take enough folic acid before and while they are pregnant. Spina bifida happens when the spine does not develop normally. Anencephaly happens when the skull and the brain do not develop normally.

What is folic acid ?
Folic acid is a vitamin. Folic acid, also called folate or folacin, is found in some vitamin pills.

How do you make sure you get enough folic acid ?
All women should take vitamins that contains folic acid before they get pregnant. You can get some folic acid from eating some foods. But it is hard to get enough folic acid from your diet. It is better to take vitamins that contain folic acid.

• grains such as whole-wheat bread.
• dark green vegetables such as spinach and broccoli.
• meat such as liver.
• beans such as lentils and kidney beans.

Why take folic acid before you get pregnant ?
Neural tube defects occur 25 to 29 days after a woman gets pregnant. At that time, many women are not even aware that they are pregnant.

Because these defects form so early, you should begin taking vitamins that contain folic acid before you get pregnant. Begin taking folic acid when you stop using birth control.

Women need more folic acid during pregnancy and breastfeeding than they do normally. So you should continue taking folic acid all the time that you are pregnant.

The guidelines highlight more current research and clinical trials that further demonstrate the positive, preventative benefit of increasing the level of folic acid intake, along with a multivitamin, at least three months prior to conception. This research concludes that an increase in folic acid supplementation can dramatically reduce birth defects such as neural tube defects (e.g. spina bifida), and possibly other birth abnormalities such as congenital heart disease, urinary tract problems, oral facial clefts, limb defects, and some pediatric cancers.

Folic acid helps produce and maintain new cells, and is important during the early embryonic and fetal periods when rapid cell division and growth are occurring. The authors of the guideline estimate that the incidence of some birth defects could be cut in half if women of childbearing age consumed an adequate amount of folic acid, either by eating sufficient quantities of food fortified with folic acid or by taking vitamin supplements.

It is estimated that at least 5% of babies are born with some serious congenital abnormality, while another 2% to 3% have defects that can be recognized prenatally (e.g. by non-invasive screening test, through invasive diagnostic testing, or at birth) and 2% will have developmental or functional anomalies recognized during the first year of life. Due to prenatal screening and awareness programming about folic acid supplementation, the birth prevalence of neural tube defects has declined in Canada from a rate of ten per 10,000 live births in 1991 to 5.8 per 10,000 total births (live births and stillbirths) in 1999. The multidisciplinary panel that authored the guidelines suggests that adherence to new standards of folic acid supplementation could accelerate these improving rates dramatically.

Specifically, the clinical guidelines recommend that:

Women with no personal health risks, planned pregnancy, and good compliance require a good diet of folate-rich foods and daily supplementation with a multivitamin with folic acid (0.4-1.0 mg) for at least two to three months before conception and throughout pregnancy and the postpartum period (4-6 weeks and as long as breastfeeding continues).

Women with compromised health or particular health conditions such as insulin dependent diabetes, obesity, or those with a previous child in the family with a neural tube defect require increased dietary intake of folate-rich foods and daily supplementation, with multivitamins with 5 mg folic acid, beginning at least three months before conception and continuing until 10 to 12 weeks post conception. From 12 weeks post-conception and continuing throughout pregnancy and for four to six weeks after the baby is born (or as long as breastfeeding continues), supplementation should consist of a multivitamin with folic acid (0.4-1.0 mg).

Extra efforts need to be made to counsel more vulnerable women (e.g. those with a variable diet, no consistent birth control, and possible substance use) about the prevention of birth defects and health problems via folic acid and multivitamin supplementation. It is recommended that they also receive a higher dose of folic acid (5 mg) with multivitamin

All women who plan to have children are advised to start their folic acid supplementation as early as three months before they conceive.

Women taking a multivitamin containing folic acid should not take more than one daily dose of vitamin supplement, as indicated on the product label.

The federal government should consider increasing the fortification of flour with folic acid to 300 mg/100 g from the current level of 140 mg/100 g and additional fortification with multivitamins. Since 1998, there has been mandatory folic acid fortification of white flour, enriched pasta, and cornmeal in Canada.

Women of childbearing age are advised to maintain a healthy diet, as recommended in Eating Well With Canada's Food Guide (Health Canada), in addition to folic acid and multi-vitamin supplementation. Foods containing excellent to good sources of folic acid are fortified grains, spinach, lentils, chick peas, asparagus, broccoli, peas, Brussels sprouts, corn, and oranges. (NB: Despite this dietary advice, it is unlikely that diet alone can provide the levels recommended for those planning to have children.)

Health professionals such as physicians, gynaecologists, obstetricians, mid-wives and public health officials should increase their efforts to make women aware of the new facts about folic acid supplementation during the normal course of their interaction with women seeking health services such as a PAP test, an annual exam or the renewal of birth control prescriptions.

Are there tests for neural tube defects ?
All women can have either a blood test or an ultrasound to test for neural tube defects when they are 3 to 6 months pregnant. (An ultrasound takes a picture of the baby while the baby is still inside the mother).

Discuss which test you should have with your doctor. These tests will not harm your baby. Your doctor will know from the tests whether your baby has a neural tube defect.

Where can you get more information ?
Talk to your doctor about taking folic acid before you get pregnant. You can also visit www.sogc.org for more information about the new folic acid guidelines. Spina bifida and other conditions caused by neural tube defects can be prevented. Give you baby a healthy start on life.

Further Reading

• Folate fortification and supplementation.Are we there yet?
  Benjamin Bar-Oz, Gideon Koren, Patricia Nguyen, Bhushan M. Kapur
• Bio-monitoring the elimination of folic acid-preventable spina bifida and anencephaly
  Guest Editorial
• Pre-conceptional Vitamin/Folic Acid Supplementation 2007: The Use of Folic Acid in Combination With a Multivitamin Supplement for the Prevention of Neural Tube Defects and Other Congenital Anomalies
• Periconception folic acid supplementation
  Gideon Koren, MD, FRCPC
• Periconceptional Folate Preventing Neural Tube Defects
  
• Recommendations for Folic Acid to Prevent Neural Tube Defects
  
• Other articles